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STATE OF CALIFORNIS WATER RESOURCES CONTROARD FORM `B': UND RGROUND STORAGE TANK PR RAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 110 ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION [:]7 PERMANENTLY CLOSED TAN MARK ONLY ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK ❑8 TANK REMOVED (J W FACILITY/SITE NAME WHERE TANK IS INSTALLED: lsp S� 7�7 ..11 - FARM TANK-YES❑ NO ❑ a) cn 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY cn A. OWNERS TANK ID q Q B. MANUFACTURED BY: Cc. D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED a 11. TANK CIWTENTS IF(A.1) S MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MA MORKED,CO LETE ITEM D. A. 1 TOR VEHICLE FUEL 2 PETROLEUM C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W HAZARDOUS SUBSTANCE STORED&C.A.S.K III. TANK CONSTR��'UIIIyyyCN��9TION MARK ONE ITEM ONLY IN BOX A,B,C.8 D WALLED ❑3SINGtE WALLEDWITH EXTERIOR LINEA ❑95 UNKNOWN A. TYPE OF ❑ LE SYSTEM 2 SINGLE WALLED F-14 SECONDARY CONTAINMENT ❑ 99 OTHER 11 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHEN LICLINING C.INTERIOR F] 5 GLASS LINING F76 UNUNED UNKNOWN LINING ❑ SLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI RAP El FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION LE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE Z. A. SYSTEM TYPE ACl SUCTI A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 KNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A Ufi CoN A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKN W A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S IVISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S dE NIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P B 95 UNKNOW P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAB TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 6 ° i-I ov CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE L/I V6 5 i� PERMIT NUMSER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M SYC FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE DATAAPPLICATION, FORM A',UNLESS ACURRENT FORMA' HAS BEEN `/F'IILE�ED